091214 anatomy of spine

Question 1

cervical and lumbar vertebrae are more prone to injury because

Answer 1

increased motion of cervical area

increased weight bearing of lumbar area

Question 2

if you have problem going on w/ thoracic area, think..

Answer 2

maybe tumor instead of just musculoskeletal, b/c thoracic area has less movement and greater stability with the rib cage

Question 3

exam of musculoskeletal spine

Answer 3

observe
palpate

ROM exam
neuromuscular exam (muscle testing, sensory testing, reflex testing)
special tests (spurling’s, Llamette’s)
examine related areas (shoulder for cervical spine, hip for lumbar spine)

Question 4

myotome

Answer 4

muscle fibers innervated by motor axons within each segmental nerve root

Question 5

dermatome

Answer 5

area of skin innervated by the sensory axons within each segmental nerve root

Question 6

shingles

Answer 6

acute neuralgia confined to dermatome distribution of specific spinal or cranial sensory nerve root

Question 7

palpation of hyoid bone-what dermatome level is it at?

Answer 7

C3

Question 8

causes of muscle weakness

Answer 8

muscle strain
pain/reflex inhibition
peripheral nerve injury
nerve root lesion (myotome)
upper motor neuron lesion (stroke, MS)
tendon pathology
avulsion
pshychologic (no effort)

Question 9

Lhermitte’s sign

Answer 9

passive anterior cervical flexion elicits electric-like sesation down the spine or extremities

implies cervical spinal cord pathology

Question 10

Spurling’s neck compression test

Answer 10

with cervical spine extension, rotation, and lateral flexion, you get reproduction of radicular symptoms

implies cervical nerve root pathology

Question 11

Hoffmann’s sign

Answer 11

flick the pt’s middle finger distal phalanx
positive test would show that pt’s ipsilateral thumb and index finger would flex-adduct

implies upper motor neuron process affecing cervical spine or brain, but not all who test positive for Hoffmann’s do have UMN process (could be an anxious pt, etc)

Question 12

straight leg raise test (or Lasegue sign)

Answer 12

patient lies supine while leg is raised passively with the knee extended. examiner stops raising the leg when the pt feels pain

positive test would be leg pain being elicited at 30-70 degrees

implies lumbar nerve root pathology (L5 or S1)

Question 13

femoral nerve stretch test

Answer 13

pt placed in prone position while the knee is flexed

positive test is when it reproduces pt’s pain in anterior thigh

implies upper lumbar nerve root pathology

Question 14

what should you think of with regards to upper motor neuron injury? (what types of causes?)

Answer 14

spinal cord injury
brain injury or stroke
myelopathy
CNS lesion

Question 15

when you hear lower motor neuron injury, what cuases should you think of?

Answer 15

peripheral nerve entrapment

radiculopathy

Question 16

red flags for serious conditions of spine

Answer 16

malignancy (hx of cancer, unexplained weight loss, age >50)

spinal fracture (major trauma, minor trauma or strenuous lifting in older or osteoporotic individual, prolonged corticosteroid use, osteoporosis, advanced age >70yo)

infection (constitutional symptoms, recent bacterial infection like UTI or skin or lungs, immunosuppression, IV drug user)

Question 17

lumbar strain hx is usually

Answer 17

axial low back pain after acute injury or long time working in yard, etc.

stiffness and limited ROM, localized tenderness in muscle

neuro exam is normal

Question 18

treatment for lumbar strain

Answer 18

relative rest
anti-inflam
usually PT is not necessary but if ongoing for more than 1 month, should do PT

Question 19

radiculopathy

Answer 19

most commonly from posterolateral herniation

means a pinched nerve root in the spine

in cervical spine: C6, C7 radiculopathies are most common

in lumbar spine: L5, S1 radiculopathies most common

Question 20

dermatomes

Answer 20

see dermatome map to review distribution

Question 21

pathophysiology of nerve root compression

Answer 21

two things:

mechanical compression– induces neural ischemia and increased intraneural pres, edema or nerve root and dorsal root ganglia. dura is sensitive

biochemical irritation–nucleus pulposis contains cytokines, leukotrienes, cox-2, interleukin-1, TNFalpha. biochemical irritation can cause apoptosis of DRG cells

Question 22

disc herniation hx

Answer 22

often picking up something not necessarily even heavy, get pain in the limbs more so than axial

can be acute or also can be insidious

Question 23

what makes lumbar disc herniation worse?

Answer 23

sitting
bending
cough, sneeze

Question 24

what makes cervical disc herniation worse?

Answer 24

movement, especially towards affected side (like the Spurling’s test)

Question 25

disc herniation exam findings

Answer 25

myotomal weakness dermatomal pain, numbness, tingling decreased or absent reflex of affected nerve Spurling or straight leg raise positive

Question 26

treatments for disc herniation

Answer 26

``` activity modification pain medication (NSAIDs (for the biochemical effects), neuromodulators like gabapentin and pregabalin, prednisone, limited opioids) ``` PT epidural steroid injection for pain control

Question 27

disc herniation indications for discectomy

Answer 27

progressive weakness refractory symptoms bowel or bladder dysfxn myelopathy 70-80% improve without surgery

Question 28

ankylosing spondylitis

Answer 28

SI joint-sclerotic (inflam eats away) late-you get thin calcifications in anterior ligament of the spine--get fused entire lumbar spine--limited ROM, bamboo spine. can get SI joint completely fused.

Question 29

early stage of ankylosing spondylitis

Answer 29

widening of SI joint, adjacent sclerosis | posterior longitudinal ligament sclerosis

Question 30

late stage of ankylosing spondylitis

Answer 30

fusion of both SI joints symmetric syndesmophytes bridging all vertebral bodies--get bamboo spine ossification of anterior, posterior, and interspinous longitudinal ligaments

Question 31

ankylosing spondylitis involves inflam of?

Answer 31

SI joints axial skeletal joints enthesitis chondritis osteitis

Question 32

systemic effects of ankylosing spondylitis

Answer 32

lung fibrosis iritis CV

Question 33

what lab marker is positive for ankylosing spondylitis

Answer 33

90% HLA-B27 positive (but if positive, doesn't mean you have it) ESR, sed rate

Question 34

spondylolisthesis can be very bad b/c

Answer 34

this bilateral defect causes slippage of the vertebrae, causing neuro problems

Question 35

arthropathy

Answer 35

disease of a joint

Question 36

60 yo degenerative changes of spine

Answer 36

degenerative disc | facet arthropathy

Question 37

facet joint arthropathy hx

Answer 37

gradual onset low back pain lumbar: worse w/ standing, walking and extension. better with sitting and lying cervical: worse with cervical extension

Question 38

etiology of facet joint arthropathy

Answer 38

gradual degenerative changes or osteoarthritis to the facet joints

Question 39

exam findings of facet joint arthropathy

Answer 39

non specific | pain worse w/ active extension, relieved by flexion

Question 40

lumbar stenosis hx

Answer 40

slowly progressive pain in back and one or both legs worse with standing and walking better with lumbar flexion and sitting (biomechanically, when we extend our spine, it actually narrows the spinal canal)

Question 41

diff btwn lumbar stenosis and peripheral vascular disease symptoms

Answer 41

person with PVD can just stop and stand (they don't need to bend or change spinal condition, as long as there's enough oxygen to muscles their pain will go away) spinal stenosis-need to lean over something

Question 42

lumbar stenosis exam findings

Answer 42

check pulse - if pulse is good, they don't have peripheral vascular disease (can rule this out of differential) no focal findings neuro exam is normal

Question 43

etiology of lumbar stenosis

Answer 43

disc disease osseous thickening of bone, facet joints, spondylolisthesis thickening of ligamentum flavum all of the above can contribute to the disease

Question 44

lumbar stenosis

Answer 44

``` PT gait aid-facilitate flexion NSAIDs, neuromodulators epidural steroids surgical treatment if reallyk intolerable ```

Question 45

in older pts, compression fracture in spine usually occurs where

Answer 45

in L1-L4

Question 46

compression fractures of vertebrae tend to occur where in the veretebrae?

Answer 46

anterior wedge

Question 47

compression fractures-majority of them occur in whom?

Answer 47

people with osteoporosis

Question 48

hx of compression fracture

Answer 48

usually sudden onset of thoracic or lumbar pain can be related to trauma or often, little or no trauma worse with flexion and movement better with rest usually no leg pain unless there's retropulsion and nerve is affected

Question 49

exam findings for compression fracture

Answer 49

local tenderness | painful lumbar ROM (especially flexion)

Question 50

imaging for compression frac

Answer 50

get plain XR | consider MRI or CT if you think it's pathologic fracture

Question 51

treatment for compression frac

Answer 51

``` acetaminophen, calcitonin, mild opioids consider bracing (if lot of pain) ```

Question 52

hx of cauda equina syndrome

Answer 52

back pain leg pain, numbness, weakness saddle anesthesia bowel and bladder dysfunction

Question 53

etiology of cauda equina syndrome

Answer 53

large disc herniation compressing cauda equina most common (also could be epidural tumor, abscess, or hematoma)

Question 54

exam findings for cauda equina syndrome

Answer 54

reduced or absent reflexes, weakness, decreased rectal tone

Question 55

treatment for cauda equina syndrome

Answer 55

emergency surgery

Question 56

cervical myelopathy can be from acute or chronic condition-true or false?

Answer 56

true

Question 57

key difference btwn cervical and lumbar stenosis?

Answer 57

cervical-can affect upper motor neurons lumbar-past L1 and L2, is just lower motor neuron problem

Question 58

hx of cervical myelopathy

Answer 58

usually over 50 yrs old varied presentation often loss of fine motor skills and hand clumsiness gait disturbance may or may not have bowel or bladder effects motor weakness lower extremity numbeness, weakness, pain

Question 59

exam findings of cervical myelopathy

Answer 59

upper and lower extremities with predominantly upper motor neuron finds and weakness below level of cord involvement positive Babinski, ankle clonus, Hoffmann's sign Llhermitte sign Romberg sign (close eyes and stand)-may be positive due to loss of proprioception wide based gait b/c of the risk of fall

Question 60

treatment for cervical myelopathy

Answer 60

usually surgical (cervical decompression-laminectomy)